Inspection Reports for
Pleasanton South Nursing and Rehab
905 W Oaklawn Rd, Pleasanton, TX 78064, TX, 78064
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
180% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the resident's family and representatives of significant changes in the resident's condition and death, as well as failure to maintain accurate and complete medical records for residents.
Complaint Details
The complaint investigation focused on the facility's failure to notify Resident #6's family of her death and significant condition changes, and failure to maintain accurate medical records for Residents #5 and #6. The investigation included interviews with staff and review of policies, revealing lapses in notification and documentation procedures.
Findings
The facility failed to notify Resident #6's family of her death and significant changes in condition, contrary to policy and standard practice. Additionally, the facility failed to maintain complete and accurate medical records for Residents #5 and #6, including documentation of death, pronouncement, notifications, and disposition of the body. These failures could place residents at risk of inadequate care and family distress.
Deficiencies (2)
Failure to notify resident's family of significant changes and death for Resident #6.
Failure to maintain complete and accurate medical records for Residents #5 and #6, including documentation of death and notifications.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in failure to notify family of Resident #6's death and incomplete documentation. |
| RN B | Registered Nurse | Named in documentation of Resident #5's move and lack of death documentation. |
| RN C | Registered Nurse | Named in pronouncement of Resident #5's death and failure to document events. |
| DON | Director of Nursing | Provided statements on facility policies and expectations regarding notification and documentation. |
Inspection Report
Deficiencies: 2
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with the Medicaid Pre-admission Screening and Resident Review (PASARR) requirements, specifically regarding the incorporation of PASARR Level II recommendations into resident assessments, care planning, and transitions of care.
Findings
The facility failed to initiate a Nursing Facility Specialized Services (NFSS) within 20 business days following the date services were agreed upon in the IDT meeting for Resident #1, causing potential delays in specialized services for residents with mental health disorders. Interviews and record reviews revealed delays related to Medicaid approval and communication issues with PASARR and Medicaid authorities.
Deficiencies (2)
Failure to incorporate PASARR Level II recommendations into resident assessment, care planning, and transitions of care for Resident #1.
Failure to initiate NFSS within 20 business days following the IDT meeting agreement for Resident #1.
Report Facts
Residents affected: 1
Date of admission: Sep 27, 2024
BIMS score: 12
Delay in therapy start: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Discussed delay in therapy services and Medicaid approval | |
| Director of Rehabilitation (DOR) | Reported therapy start delay and current therapy status | |
| Administrator | Communicated with PASARR office and discussed Medicaid approval issues | |
| BOM | Reported Medicaid transfer and billing status | |
| LIDDA case manager | Provided information on Medicaid system procedures and service offers |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 6, 2024
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services, drug labeling, and room size requirements at Pleasanton South Nursing and Rehabilitation.
Findings
The facility failed to provide pharmaceutical services meeting residents' needs, including medication administration errors and unlabeled tube feeding bags. Additionally, the facility did not provide the minimum required square footage per resident in multiple rooms.
Deficiencies (3)
Failed to provide routine drugs and biologicals and pharmaceutical services for 3 of 7 residents, including medication sharing and missed doses of Velphoro.
Failed to ensure drugs and biologicals were labeled correctly, including missing resident name, date, and time on tube feeding bag for 1 of 5 residents.
Failed to provide rooms with at least 80 square feet per resident in 43 of 43 resident rooms reviewed.
Report Facts
Residents affected: 3
Residents affected: 1
Rooms affected: 43
Medication doses missed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Witnessed residents sharing supplement and provided information about medication delays and supplement sharing | |
| DON | Director of Nursing | Provided information about medication delays and monitoring of Resident #51 |
| ADON | Assistant Director of Nursing | Observed and corrected unlabeled feeding bags |
| Administrator | Administrator | Interviewed about room waiver request for deficient room sizes |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation triggered by an elopement incident involving Resident #1 who exited the facility unnoticed on 08/13/2024.
Complaint Details
The complaint investigation was initiated after Resident #1 eloped from the facility on 08/13/2024. Immediate Jeopardy was identified on 08/27/2024 and removed on 08/29/2024 after corrective actions were implemented. The facility remained out of compliance at a severity level of potential for more than minimal harm due to ongoing monitoring needs.
Findings
The facility failed to ensure adequate supervision and accident hazard prevention, resulting in an Immediate Jeopardy (IJ) situation due to Resident #1 eloping. The facility implemented corrective actions including staff in-service training, resident re-assessment for elopement risk, installation of wander guards, and monitoring systems. Additionally, a failure in infection control was identified when a CNA did not wear a gown while providing care to a resident on isolation precautions.
Deficiencies (2)
Failure to ensure the environment was free of accident hazards and provide adequate supervision to prevent Resident #1 from eloping.
Failure to follow infection prevention and control protocols by not wearing a gown while providing incontinent care to Resident #2 on isolation precautions.
Report Facts
Staff count: 75
Staff worked during incident period: 68
Staff not signed in-service: 16
Staff signed in-service: 63
Resident elopement risk score: 5
Resident BIMS score: 5
Resident BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-AB | Certified Nursing Assistant | Named in infection control deficiency for failing to wear a gown while providing incontinent care to Resident #2. |
| DON | Director of Nursing | Interviewed regarding Resident #1 elopement and infection control policies. |
| Administrator | Interviewed regarding Resident #1 elopement and corrective actions. | |
| MA D | Medication Aide | Mentioned in relation to Resident #1 medication administration and elopement event. |
| LPN A | Licensed Practical Nurse | Received in-service training after Immediate Jeopardy was identified. |
| RN B | Registered Nurse | Received in-service training after Immediate Jeopardy was identified. |
| CNA C | Certified Nursing Assistant | Received in-service training after Immediate Jeopardy was identified. |
| CNA E | Certified Nursing Assistant | Received in-service training after Immediate Jeopardy was identified. |
| LPN F | Licensed Practical Nurse | Received in-service training after Immediate Jeopardy was identified. |
| LPN G | Licensed Practical Nurse | Received in-service training after Immediate Jeopardy was identified. |
| MA H | Medication Aide | Received in-service training after Immediate Jeopardy was identified. |
| RN I | Registered Nurse | Received in-service training after Immediate Jeopardy was identified. |
| CNA J | Certified Nursing Assistant | Received in-service training after Immediate Jeopardy was identified. |
| CNA K | Certified Nursing Assistant | Received in-service training after Immediate Jeopardy was identified. |
| CNA L | Certified Nursing Assistant | Received in-service training after Immediate Jeopardy was identified. |
| CNA M | Certified Nursing Assistant | Received in-service training after Immediate Jeopardy was identified. |
| Housekeeping N | Housekeeping Staff | Received in-service training after Immediate Jeopardy was identified. |
| Housekeeping O | Housekeeping Staff | Received in-service training after Immediate Jeopardy was identified. |
| DA P | Dietary Aide | Received in-service training after Immediate Jeopardy was identified. |
| Human Resources Director U | Human Resources Director | Received in-service training after Immediate Jeopardy was identified. |
| LPN W | Licensed Practical Nurse | Received in-service training after Immediate Jeopardy was identified. |
| Activities Director X | Activities Director | Received in-service training after Immediate Jeopardy was identified. |
| PT Assistant Y | Physical Therapy Assistant | Received in-service training after Immediate Jeopardy was identified. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 2, 2024
Visit Reason
Annual survey inspection of Pleasanton South Nursing and Rehabilitation to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Oct 22, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, staff identification, and nurse aide certification at Pleasanton South Nursing and Rehabilitation.
Findings
The facility failed to ensure that all staff providing direct care wore name tags identifying their name and job title, which affected residents' ability to recognize caregivers. Additionally, one nurse aide was working beyond four months without being certified or enrolled in an approved training course, placing residents at risk due to unknown skill levels.
Deficiencies (2)
Failure to ensure all staff providing direct care identify themselves by name and job title.
Failure to ensure nurse aide who worked more than 4 months was trained and competent; nurse aide was not certified within required timeframe.
Report Facts
Residents reviewed for administration: 25
Nurse aides reviewed: 3
Hire date: Aug 1, 2022
Survey completion date: Oct 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN F | Licensed Vocational Nurse | Named in finding for not wearing a name tag |
| CNA B | Certified Nursing Assistant | Named in finding for not wearing a name tag |
| MA C | Medical Assistant | Named in finding for not wearing a name tag |
| NA A | Nurse Aide | Named in finding for not wearing a name tag and not certified within required timeframe |
| DON | Director of Nursing | Named in finding for not wearing a name tag identifying current role |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, nursing staff competencies, medical record documentation, and quality assurance processes.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for residents, ensure nursing staff competency in CPR and AED use, maintain accurate and complete medical records, and properly report adverse events to the QAPI committee. Immediate jeopardy was identified due to failure to use AED during CPR for a resident and lack of staff competency in emergency response.
Deficiencies (4)
Failure to develop and implement complete care plans addressing residents' needs including PASRR status, diet updates, and durable medical equipment.
Failure to ensure nursing staff competency in CPR and AED use, resulting in immediate jeopardy due to denial of life-saving measures during a resident's cardiac arrest.
Failure to maintain accurate, complete, and timely medical record documentation of CPR care provided to a resident.
Failure to establish and implement effective QAPI policies and procedures for adverse event monitoring and reporting, including failure to report a CPR event to the QAPI committee.
Report Facts
Residents reviewed for care planning deficiencies: 33
Residents reviewed for CPR care: 29
Nurses reviewed for CPR competency: 21
Duration of CPR performed: 9
Residents with full code status: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Involved in CPR care for Resident #61; did not use AED; did not document CPR details |
| RN C | Registered Nurse | Involved in CPR care for Resident #61; did not use AED; did not document CPR details |
| MDS H | Responsible for PASRR care plans; unable to locate PASRR care plan for Resident #46 | |
| ADMN AA | Administrator | Acknowledged care plan deficiencies and responsibility for updating care plans |
| DON | Director of Nursing | Responsible for staff training and competency; conducted mock CPR/AED training; unaware of AED use during CPR event |
| LVN P | Licensed Vocational Nurse | Received mock CPR/AED training with return demonstration |
| RN K | Registered Nurse | Received mock CPR/AED training with return demonstration |
| LVN J | Licensed Vocational Nurse | Received mock CPR/AED training with return demonstration |
| LVN M | Licensed Vocational Nurse | Received mock CPR/AED training with return demonstration |
| LVN F | Licensed Vocational Nurse | Received mock CPR/AED training with return demonstration |
| LVN E | Licensed Vocational Nurse | Received mock CPR/AED training with return demonstration |
| RN O | Registered Nurse | Received mock CPR/AED training with return demonstration |
| RN N | Registered Nurse | Received mock CPR/AED training with return demonstration |
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 15
Date: Aug 9, 2023
Visit Reason
The inspection was an annual survey to assess compliance with regulatory requirements including resident rights, care planning, medication administration, staffing, and safety.
Findings
The facility had multiple deficiencies including failure to accommodate resident needs, incomplete advance directives, inadequate notice of Medicare non-coverage, failure to support resident grievances, incomplete background checks for new staff, failure to timely report abuse and neglect, incomplete care plans, failure to provide basic life support including AED use during CPR, medication errors, failure to post nurse staffing census, unsafe food handling practices, incomplete medical records, ineffective pest control, and inadequate room size.
Deficiencies (15)
Resident #13's call light was not within reach while in bed, risking inability to notify staff.
Resident #24's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was not properly executed due to missing notary signature.
Facility failed to inform Medicaid-eligible residents in writing about potential liability for services not covered for 4 of 5 residents reviewed.
Facility failed to support resident grievances and did not document or resolve grievances for several months.
New staff (3 of 5 reviewed) were hired without completed background checks prior to hire date.
Facility failed to timely report HVAC system failure and abuse allegations to state agency.
Facility failed to provide basic life support including use of AED during CPR for Resident #61.
Facility failed to ensure Resident #54's oxygen order included liter parameters.
Facility failed to ensure licensed nurses had competencies and skills for CPR and AED use.
Facility failed to post nurse staffing information including resident census for 2 of 2 days and for 18 months of postings.
Facility ordered unpasteurized eggs and served soft yolks to residents, risking foodborne illness.
Facility failed to maintain complete, accurate, and accessible medical records for Resident #61, including CPR documentation.
Facility failed to establish and implement effective adverse event monitoring and QAPI review for Resident #61's CPR event.
Facility failed to provide rooms with at least 80 square feet per resident in 43 of 44 resident rooms reviewed.
Medication errors occurred including administration of Carafate with other meds and crushing extended-release metoprolol.
Report Facts
Medication errors: 2
Resident census: 63
Resident rooms with insufficient square footage: 43
Wasp nests: 7
Live wasps: 7
Nurses employed: 22
Nurses interviewed for CPR AED training: 21
Residents requesting CPR: 29
Medication error rate: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN R | Registered Nurse | Named in failure to report complaint and CPR event documentation |
| ADON K | Assistant Director of Nursing | Named in grievance and CPR training interviews |
| LVN A | Licensed Vocational Nurse | Named in CPR event and failure to use AED |
| RN C | Registered Nurse | Named in CPR event and failure to use AED |
| MA W | Medication Aide | Named in medication error for crushing extended-release metoprolol |
| ADMN AA | Administrator | Named in multiple interviews regarding grievances, HVAC failure, pest control, and CPR event |
| DON | Director of Nursing | Named in multiple interviews regarding grievances, CPR event, training, and documentation |
| HR | Human Resources | Named in background check deficiencies and nurse staffing postings |
| LVN F | Licensed Vocational Nurse | Named in medication error for Carafate administration |
| DM | Dietary Manager | Named in food safety interview |
| Maintenance Director | Named in pest control and HVAC system failure interviews |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 31, 2023
Visit Reason
The inspection was conducted as an annual survey of Pleasanton South Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 9
Date: Jun 24, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident confidentiality, environment safety, medication management, infection control, staffing information posting, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to maintain confidentiality of resident records, unsafe and unsanitary environment conditions, expired medications stored improperly, inadequate infection control practices, failure to post nurse staffing information prominently, and insufficient resident room space.
Deficiencies (9)
Failed to respect residents' right to confidentiality by leaving computers unlocked exposing resident information.
Failed to provide a safe, clean, comfortable, and homelike environment due to dirty, damaged couches, broken dishwasher, and storage of equipment in dining areas.
Failed to provide a complete recapitulation of the resident's stay in discharge summary.
Failed to post nurse staffing data in a prominent place readily accessible to residents and visitors.
Failed to ensure expired medications were removed from the medication room and properly stored.
Failed to store, prepare, distribute and serve food in accordance with professional standards due to use of damaged blender and visible dust in kitchen.
Failed to maintain infection control program; staff changed gloves multiple times during wound care without hand hygiene.
Failed to provide minimum of 80 square feet per resident in 37 of 41 resident rooms reviewed.
Failed to maintain a safe, clean, and comfortable designated smoking area; trash cans contained paper trash and cigarette ends posing fire hazard.
Report Facts
Residents affected: 2
Medication carts reviewed: 4
Residents affected: 65
Residents affected: 1
Facility rooms with insufficient square footage: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Failed to lock computer exposing resident information | |
| LVN G | Failed to lock medication cart computer exposing resident information | |
| RN F | Noted medication cart computer left unlocked and took corrective action | |
| Administrator | Interviewed regarding confidentiality, environment, expired medications, staffing posting, and smoking area | |
| DON | Director of Nursing | Interviewed regarding confidentiality, infection control, expired medications, staffing posting |
| RN C | Observed expired medications in medication room | |
| ADON | Assistant Director of Nursing | Interviewed regarding discharge summaries and expired medication responsibilities |
| Maintenance Director | Interviewed regarding storage of broken dishwasher and cleaning kitchen pipes | |
| DM | Dietary Manager interviewed regarding kitchen sanitation issues | |
| RN A | Observed failing to perform hand hygiene between glove changes during wound care |
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